Information Collection

Peace Corps Volunteer Authorization for Examination and/or Treatment

IC 236890 under ICR 202405-1240-004 · OMB 1240-0059.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0059 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CA-15 Peace Corps Volunteer Authorization for Examination and/or Treatment	Form and Instruction
CA-15 Peace Corps Volunteer Authorization for Examination And/ CA-15 pdf.updated 4.24.24.pdf www.ecomp.dol.gov	Form and Instruction
OMB 1240-0059 Peace Corps Supporting Statement. draft 4.26.24.updated 5.7.24.docx Supporting Statement	IC Document

IC Title:

Peace Corps Volunteer Authorization for Examination and/or Treatment

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 10.730 20 CFR 10.731

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CA-15	Peace Corps Volunteer Authorization for Examination And/Or Treatment	CA-15 pdf.updated 4.24.24.pdf	https://www.ecomp.dol.gov	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: DOL/GOVT-1

FR Citation: 81 FR 47418

Number of Respondents: 252

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	252	0	252
Annual IC Time Burden (Hours)	63	0	63
Annual IC Cost Burden (Dollars)	252	93	159

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement	OMB 1240-0059 Peace Corps Supporting Statement. draft 4.26.24.updated 5.7.24.docx	05/17/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.